Healthcare Provider Details

I. General information

NPI: 1861849044
Provider Name (Legal Business Name): MAYA ROSA GONZALEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 03/08/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549TH HOSPITAL CENTER/BDAACH UNIT #15245
APO AP
96271-0000
US

IV. Provider business mailing address

PSC 444 BOX 2072
APO AP
96297-0021
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-1857
  • Fax:
Mailing address:
  • Phone: 315-737-5669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-18248
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: